Health Assessment Exam #1 (Ch. 1,3,4,8,9,10,12,18,27,29)
Questions With Complete Solutions
A patient has recently received health insurance and would like
to know how often he should visit the provider. How do you
respond?
a. "it would be most efficient if you visit on an annual basis"
b. "there is no recommendation for the frequency of health care
visits"
c. "your visits may vary, depending on your level of wellness"
d. "your visits will be based on your preference" Correct
Answers c. "your visits may vary, depending on your level of
wellness"
A patient is in the emergency department with nausea and
vomiting. Which would you include in the database?
a. a complete health history and full physical examination
b. a diet and GI history
c. previously identified problems
d. start collection of data in conjunction with lifesaving
measures Correct Answers b. a diet and GI history
A patient says she is very nervous and nauseated, and she feels
like she will vomit. This data would be what type of data?
a. objective
b. reflective
c. subjective
d. introspective Correct Answers c. subjective
,Are vital signs subjective or objective data? Correct Answers
Objective because they can be measured by a health care
professional
Arm pressure, person may be sitting or lying, with bare arm
supported at heart level. What are the steps of taking blood
pressure? Correct Answers 1. Palpate brachial artery; with cuff
deflated, center it about 1 inch above brachial artery and wrap it
2. Palpate brachial artery
3. Inflate cuff until artery pulsation obliterated and then 20 to 30
mm Hg beyond
4. Deflate cuff quickly and completely; wait 15 to 30 seconds
before reinflating so blood trapped in veins can dissapate
Arteries, aorta, away, oxygen Correct Answers
As you proceed through health history, measurements and vital
signs, note following points that will add up to general survey.
What are the four areas you should be aware of during a GS?
Correct Answers -physical appearance
-body structure
-mobility
-behavior
At lower oxygen saturations, what is more accurate than the
pulse oximeter? Correct Answers An earlobe probe is more
accurate and less affected by peripheral vasoconstriction
Does a pt require a complete head-to-toe physical examination
every 24 hours? Correct Answers NO
,-pt does require consistent specialized examination at least every
8 hours that focuses on certain parameters
-note that some measurements such as daily wt, abdominal girth,
or circumference of a limb must be taken carefully
-REMEMBER: many assessments must be done frequently
throughout course of a shift
During palpation, what should fingers and thumb be used for?
Correct Answers -detection of position, shape, and consistency
of an organ or mass
During palpation, what should fingertips be used to feel?
Correct Answers -best for fine tactile discrimination of skin
texture, swelling, pulsation, and determining presence of lumps
During palpation, what should the base of fingers or the ulnar
surface of hand be used for? Correct Answers -best for
vibration
**-vibrations are felt on the ulnar side of hand
During palpation, what should the dorsa of hands and fingers be
used for? Correct Answers -best for determining temperature
because skin here is thinner than on palms
During palpation, what type of palpation should you start with
and why? What steps are next? Correct Answers 1. start with
LIGHT palpation to detect surface characteristics and accustom
person to being touched
-1 cm
2. then deeper palpations when needed
-intermittent pressure better than one long continuous palpation
, -5 to 8 cm or 2-3 in
ALSO: bimanual palpation- requires use of both hands to
envelop or capture certain body parts or organs such as kidneys,
uterus or adnexa for precise delimitation
During the elevation phase of the nursing process, which action
would be included?
a. validating the nursing diagnosis
b. establishing priorities related to patient care
c. providing information to the patient and family members
d. establishing a timeline for planned outcomes Correct
Answers c. providing info to the patient and family members
HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT
THAN SOLID ORGANS Correct Answers
How can you assess factors during the palpation step? Correct
Answers by using different parts of the hands
How do you measure height? Correct Answers -Use wall-
mounted device or measuring pole on scale
-Align extended headpiece with top of head
-person should be shoeless, standing straight, looking straight
ahead, with feet and shoulders on hard surface
How long should you count respirations? Correct Answers -
Count for 30 seconds or 1 minute if you suspect an abnormality
How long should you count the pulse for if the rhythm is
IRREGULAR? Correct Answers 1 full minute
Questions With Complete Solutions
A patient has recently received health insurance and would like
to know how often he should visit the provider. How do you
respond?
a. "it would be most efficient if you visit on an annual basis"
b. "there is no recommendation for the frequency of health care
visits"
c. "your visits may vary, depending on your level of wellness"
d. "your visits will be based on your preference" Correct
Answers c. "your visits may vary, depending on your level of
wellness"
A patient is in the emergency department with nausea and
vomiting. Which would you include in the database?
a. a complete health history and full physical examination
b. a diet and GI history
c. previously identified problems
d. start collection of data in conjunction with lifesaving
measures Correct Answers b. a diet and GI history
A patient says she is very nervous and nauseated, and she feels
like she will vomit. This data would be what type of data?
a. objective
b. reflective
c. subjective
d. introspective Correct Answers c. subjective
,Are vital signs subjective or objective data? Correct Answers
Objective because they can be measured by a health care
professional
Arm pressure, person may be sitting or lying, with bare arm
supported at heart level. What are the steps of taking blood
pressure? Correct Answers 1. Palpate brachial artery; with cuff
deflated, center it about 1 inch above brachial artery and wrap it
2. Palpate brachial artery
3. Inflate cuff until artery pulsation obliterated and then 20 to 30
mm Hg beyond
4. Deflate cuff quickly and completely; wait 15 to 30 seconds
before reinflating so blood trapped in veins can dissapate
Arteries, aorta, away, oxygen Correct Answers
As you proceed through health history, measurements and vital
signs, note following points that will add up to general survey.
What are the four areas you should be aware of during a GS?
Correct Answers -physical appearance
-body structure
-mobility
-behavior
At lower oxygen saturations, what is more accurate than the
pulse oximeter? Correct Answers An earlobe probe is more
accurate and less affected by peripheral vasoconstriction
Does a pt require a complete head-to-toe physical examination
every 24 hours? Correct Answers NO
,-pt does require consistent specialized examination at least every
8 hours that focuses on certain parameters
-note that some measurements such as daily wt, abdominal girth,
or circumference of a limb must be taken carefully
-REMEMBER: many assessments must be done frequently
throughout course of a shift
During palpation, what should fingers and thumb be used for?
Correct Answers -detection of position, shape, and consistency
of an organ or mass
During palpation, what should fingertips be used to feel?
Correct Answers -best for fine tactile discrimination of skin
texture, swelling, pulsation, and determining presence of lumps
During palpation, what should the base of fingers or the ulnar
surface of hand be used for? Correct Answers -best for
vibration
**-vibrations are felt on the ulnar side of hand
During palpation, what should the dorsa of hands and fingers be
used for? Correct Answers -best for determining temperature
because skin here is thinner than on palms
During palpation, what type of palpation should you start with
and why? What steps are next? Correct Answers 1. start with
LIGHT palpation to detect surface characteristics and accustom
person to being touched
-1 cm
2. then deeper palpations when needed
-intermittent pressure better than one long continuous palpation
, -5 to 8 cm or 2-3 in
ALSO: bimanual palpation- requires use of both hands to
envelop or capture certain body parts or organs such as kidneys,
uterus or adnexa for precise delimitation
During the elevation phase of the nursing process, which action
would be included?
a. validating the nursing diagnosis
b. establishing priorities related to patient care
c. providing information to the patient and family members
d. establishing a timeline for planned outcomes Correct
Answers c. providing info to the patient and family members
HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT
THAN SOLID ORGANS Correct Answers
How can you assess factors during the palpation step? Correct
Answers by using different parts of the hands
How do you measure height? Correct Answers -Use wall-
mounted device or measuring pole on scale
-Align extended headpiece with top of head
-person should be shoeless, standing straight, looking straight
ahead, with feet and shoulders on hard surface
How long should you count respirations? Correct Answers -
Count for 30 seconds or 1 minute if you suspect an abnormality
How long should you count the pulse for if the rhythm is
IRREGULAR? Correct Answers 1 full minute
